Patient handout

DVT from prolonged immobilization (post-stroke / SCI / post-arthroplasty / prolonged ICU)

PRODUCTION

1. Your condition

This handout is for dvt from prolonged immobilization (post-stroke / sci / post-arthroplasty / prolonged icu). Your care team identified this based on: unilateral lower-extremity swelling, calf pain, or whole-leg swelling in patient with chronic immobility (post-stroke, sci, post-arthroplasty, prolonged icu >7 d, bed-bound nursing home).

Other reasons your team may use this plan: patient with established prolonged-immobility substrate (lower-extremity paralysis from stroke or sci, post-knee/hip arthroplasty within 35 d, icu stay >7 d, post-cast/orthotic immobilization) — surveillance or symptomatic screen indicated; incidental dvt identified on ct abdomen/pelvis or imaging in icu patient — confirm diagnostic + initiate ac if no contraindication; new pleuritic chest pain, dyspnea, syncope, or hemoptysis in chronically immobilized patient — concurrent pe screen mandated (perc fail; ctpa or vq if wells pe > 4).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
apixaban	10 mg BID × 7 d → 5 mg BID; consider 2.5 mg BID extended-low-dose at 6 mo if substrate persists	PO	BID; substrate-conditional duration	AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — apixaban first-line acute; AMPLIFY-EXT (PMID 23216615) — 2.5 mg BID extended-low-dose maintains protection with reduced bleed risk if substrate persists
rivaroxaban	15 mg BID × 21 d → 20 mg daily with food; OR 10 mg daily × 35 d post-major orthopedic surgery (RECORD-1/2/3) for prophylaxis; OR 10 mg daily extended-low-dose maintenance per EINSTEIN-CHOICE	PO	BID then daily; substrate-conditional duration	EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814); EINSTEIN-CHOICE (Weitz NEJM 2017 PMID 28316279) — 10 mg daily extended; RECORD-1/2/3 (PMIDs 18579812, 18582928, 18579811) — 10 mg daily × 35 d post-arthroplasty
enoxaparin	Treatment: 1 mg/kg SC BID (1 mg/kg daily if CrCl <30); Prophylaxis: 40 mg SC daily (30 mg BID for high-risk hospitalized, post-arthroplasty); SCI 8-wk bridge: 30 mg SC q12h then transition to DOAC per CSCM 2016	SC	BID treatment; daily prophylaxis; 8-wk SCI bridge	ASH 2020 (PMID 33007077); ENOXACAN-II (Bergqvist NEJM 2002 PMID 12239342) extended LMWH cancer surgery; PREVAIL (Sherman Lancet 2007 PMID 17499598) enoxaparin in stroke; CSCM 2016 SCI consortium
edoxaban	60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or with strong P-gp inhibitor) after 5-10 d LMWH bridge	PO	daily; substrate-conditional duration	Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — edoxaban after LMWH lead-in non-inferior to warfarin
warfarin	5 mg daily; INR target 2-3	PO	daily; substrate-conditional duration	TRAPS (Pengo Blood 2018) — warfarin > rivaroxaban in triple-positive APS; reasonable alternative if DOAC contraindicated; CrCl <15 → warfarin only
aspirin	81 mg PO daily — limited prophylaxis role post-arthroplasty per AAOS 2011 (only if low-risk + DOAC contraindicated)	PO	daily	AAOS 2011 — ASA acceptable post-arthroplasty in low-risk patients; NOT first-line per ACCP 2021 which favors DOAC/LMWH; do NOT substitute for treatment-dose AC in active DVT

Plan: Long-term-immobilization DVT — substrate-conditional AC duration (3 mo if reversed; extended/indefinite if persists) + mechanical-first prevention if bleed risk + SCI-specific 8-wk LMWH bridge per CSCM 2016 (ACCP 2021; ASH 2018)

3. When to call your provider

Contact your care team if any of the following happen:

New VTE despite prevention plan → restart AC + evaluate for thrombophilia + consider extended-phase AC
Pregnancy → switch to LMWH per ASH 2018
New fracture or surgery → temporary high-intensity prophylaxis

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Patient with chronic SCI develops recurrent DVT or PE despite ongoing CSCM-2016-compliant prophylaxis (LMWH bridge → DOAC) — prophylaxis-failure scenario
Post-major-orthopedic-surgery patient (THA/TKA) within 35-d RECORD prophylaxis window develops PE despite rivaroxaban 10 mg daily — prophylaxis-failure(life-threatening)
IPC mechanical prophylaxis cannot be sustained (skin breakdown, agitated patient pulling off, ICU restraints conflict, supply shortage) in patient with active AC contraindication — protection gap
ICU patient already on therapeutic AC for prior indication (afib, mechanical valve, prior VTE) develops new DVT during prolonged ICU stay (>7 d) — true prophylaxis failure or AC sub-therapeutic level
Massive acute occlusive iliofemoral DVT in chronically immobilized patient producing phlegmasia cerulea dolens (cyanosis, severe pain, arterial compromise)(life-threatening)
Major bleed on DOAC/LMWH in chronically immobilized patient with high falls risk (Hgb drop ≥2 g/dL, transfusion, ICH, retroperitoneal); chronic substrate complicates AC continuation decision(life-threatening)

5. Follow-up

Substrate reassessment at 3 mo: if reversed → STOP AC per ACCP 2021 provoked rule; if persists → continue at full or low-dose extended AC (apixaban 2.5 mg BID per AMPLIFY-EXT); enforce mechanical + pharmacologic prophylaxis going forward; PT/OT for mobility restoration; if recurrent VTE on prophylaxis → escalate to therapeutic-dose extended AC + reassess substrate

6. Sources

Guideline: ACCP/CHEST 2021 (Stevens) + ASH 2018 VTE Prevention (Schünemann) + CSCM 2016 SCI consortium + AAOS 2011 prophylaxis post-arthroplasty + RECORD 1/2/3 + CLOTS-3